Provider Demographics
NPI:1508239393
Name:CHERESTAL, FANCESCA
Entity Type:Individual
Prefix:
First Name:FANCESCA
Middle Name:
Last Name:CHERESTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 OLD IRONSIDES WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2205
Mailing Address - Country:US
Mailing Address - Phone:857-300-0153
Mailing Address - Fax:
Practice Address - Street 1:43 MONTEBELLO RD
Practice Address - Street 2:ABATEC, LLC
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-477-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS89730375103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst